Global Health Program Rich Man Poor Man Dinner 2017

TICKET ORDER FORM

Dear Friends: On March 4, 2017 the Global Health Program, Division of Community Engagement, Faculty of Medicine & Dentistry, along with our partners in the School of Public Health, Students Invested in Health Association and Medical Students’ Association, will host our annual fundraiser, the Rich Man Poor Man Dinner. Money raised from this dinner supports global health education for students and residents. Please join us at St. Basil’s Cultural Centre and enjoy the entertainment program, silent auction, and hear our keynote speaker, Dr. Ruth Beltran, Dean,

Xavier University, Dr. Jose P Rizal School of Medicine, Philippines. Please use this form to order tickets or to make a donation. Kindly return your form in the enclosed envelope or contact Cheryl Knowles by Monday, February 27, 2017. E-mail: [email protected] Phone: 780-492-8928 Fax: 780-248-1163 Office: 2-115 ECHA We look forward to seeing you there! Dr. Jill Konkin, Associate Dean, Division of Community Engagement Faculty of Medicine & Dentistry School of Public Health, Students Invested in Health Association and Medical Students’ Association

Title _________________________________ First Name ____________________________ Last Name ____________________________ Address ______________________________ _____________________________________ City _________________________________ Prov ____________ Postal Code __________ Phone _______________________________ E-mail _______________________________ NOTE: A TAX RECEIPT WILL BE ISSUED FROM U OF A GIFT PROCESSING FOR THE ELIGIBLE AMOUNT

PLEASE SELECT ONE OF THE FOLLOWING OPTIONS:  Yes! I would like to attend the dinner, and would like to purchase _________________ tickets @ $100.00 = $__________________. Please sign in upon arrival at St. Basil’s Cultural Centre at 10819-71 Avenue on March 4, 2017, 6 pm for 7 pm start.  I am not able to attend the event, but would like to purchase _____________________ tickets @ $100.00 = $__________________ for distribution to students and other guests.  I am not available for the event, but would like to make a donation in lieu of purchasing tickets by choosing the following giving option:  I wish to make a monthly gift of $ ________________________________  I wish to make a one-time gift of $ ________________________________ Signature ________________________________ Date _________________ METHOD OF PAYMENT  CASH  CHEQUE PAYABLE TO UNIVERSITY OF ALBERTA  VISA

 MASTERCARD

 AMEX

CARDHOLDER NAME

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CREDIT CARD NUMBER

_________________________________________________ EXPIRY MONTH ____________ YEAR __________

CARDHOLDER SIGNATURE ____________________________________________________________________________________________ Should you have any questions about your gift, would like more information about the dinner or how to donate an item for the silent auction, please contact Cheryl Knowles [email protected] 780-492-8928 or Wendy Brown [email protected] The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act for the purposes of raising philanthropic support for the University of Alberta. Questions concerning the collection, use, or, disposal of this information should be directed to: FOIP Liaison Officer, External Relations, University of Alberta, 3rd Floor, Enterprise Square, 10230 Jasper Avenue, Edmonton, AB T5J 4P6 Phone: (780) 492-0328 Fax: (780) 492-1862. Charitable Registration Number: 108102831RR0001